CMS/EIP Fiscal Report Center: 53
Services beginning 01/01/2016 ending 03/31/2016 Date of Report:05/12/2016 Page: 1
List order: No List
Payclass Filters:MED
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 75 315.250000 11655.0000 36.9707
Subtotal (Total Children Is Unduplicated) 75 315.250000 11655.0000 36.9707
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.500000 138.7500 39.6429
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 8.000000 600.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 7.500000 562.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 42 70.500000 3912.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 50 84.500000 6337.5000 75.0000
Subtotal (Total Children Is Unduplicated) 57 175.500000 11664.0000 66.4615
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 7.000000 350.0000 50.0000
Subtotal (Total Children Is Unduplicated) 3 7.000000 350.0000 50.0000
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Total 497.750000 23669.0000 47.5520
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Number of Children (Unduplicated) With at Least One Service 76
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Center 53
Flag Claims Units Chgs Paid
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R 25 21.250000 786.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 199 210.500000 9064.2500 111.0000
P 166 202.500000 9905.0000 9905.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
47 63.500000 3913.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 437 497.750000 23669.0000 10016.0000